EMT: Face and Neck Injuries

The presence of air in the veins, which can lead to cardiac arrest if it enters the heart.

Naturally occurring uneven pupil size

A fracture of the orbit or the bones that support the floor of the orbit.

The delicate membrane that lines the eyelids and covers the exposed surface of the eye.

Inflammation of the conjunctiva

The transparent tissue layer in front of the pupil and iris of the eye.

A branch of the internal auditory canal that connects the middle ear to the oropharynx

The ear canal; leads to the tympanic membrane

The eyeball

The muscle and surrounding tissue behind the cornea that dilate and constrict the pupil, regulating the amount of light that enters the eye; pigment in this tissue gives the eye its color

A cranial nerve (cranial nerve II) that transmits visual information to the brain

The external, visible part of the ear

The circular opening in the middle of the iris that admits light to the back of the eye

The light-sensitive area of the eye where images are projected; a layer of cells at the back of the eye that changes the light image into electrical impulses, which are carried by the optic nerve to the brain

Separation of the retina from its attachments at the back of the eye

The tough, fibrous, white portion of the eye that protects the more delicate inner structures

The muscles on either side of the neck that allow movement of the head.

A characteristic cracking sensation felt on palpation of the skin, caused by the presence of air in soft tissues.

The joint formed where the mandible and cranium meet, just in front of the ear

The small, rounded, fleshy bulge that lies immediately anterior to the ear canal

Layers of bone within the nasal cavity

The eardrum, which leis between the external and middle ear.

a. Soft tissue injuries are similar to others, but swelling may be more
severe
b. Facial bones may fracture causing airway and ventilation
obstruction
c. Eye injuries suffer soft tissue type injuries, abrasions, lacerations,
punctures, chemical burns, etc.
d. Eye injuries may cause vision disturbances
e. Eyes injured with chemicals need flushing with copious amounts
of water
f. Excessive pressure on the eye may “blow out” bones in the orbit
g. Nasal fractures may cause bleeding
h. Oral injuries may cause airway management complications

a. Inspection
i. open wounds
ii. swelling
iii. deformity of bones
iv. eye clarity without foreign objects
v. eye symmetry
vi. bone alignment in anatomical position
b. Palpation – facial bones
c. Eye examination
i. follows finger up, down, lateral
ii. can read regular print
iii. no blood visible in iris area

a. Maintain patent airway
b. Nasopharyngeal airways are contraindicated
c. May need frequent suctioning
d. Bring broken teeth to hospital with patient
e. Flush eyes contaminated with chemicals with copious amounts of
water
f. Control simple nose bleeds by pinching nostrils
g. Eye injuries require patching of both eyes
h. Stabilize impaled objects in the eye
i. Impaled objects in cheeks may be removed if bleeding obstructs
the airway
j. Patients with these injuries may be more comfortable sitting up – if
no risk of spinal injury
k. Bandaging should not occlude the mouth

a. May have underlying spinal injury
b. Open wounds may bleed profusely and cause death
c. Airway passages may be obstructed

a. Monitor airway throughout care
b. Patient may not be able to swallow with esophageal injury
c. (subcutaneous emphysema) Swelling may be related to air escape under the skin which can
“crackle” with digital pressure
d. Larynx injuries will cause changes in voice sounds
e. Air may enter the circulatory system if there is penetrating injury
to a large blood vessel in the neck

a. Single digital pressure (gloves on) to control bleeding of carotid
artery or jugular veins may be necessary
b. ALS intercept or air medical transport may be necessary in severe
cases of airway compromise
c. Occlusive dressing for large vessel wounds (after bleeding
controlled) – to prevent air entry into circulatory system

1. Tell the patient to look down while you grasp the lashes of the upper eyelid with your thumb and index finger. Gently pull the eyelid away from the eyeball.

2. Gently place a cotton-tipped applicator horizontally along the center of the outer surface of the upper eye lid.

3. Pull the eyelid forward and up, which cuases it to roll or fol back over the applicator, exposing the under surface of the eye lid.
4. If you see a foreign object on the surface of the eyelid, gently remove it with a moistened, sterile, cotton tipped applicator

1. To prepare a doughnut ring, wrap a 2" roll around your fingers and thumb seven or eight times. Adjust the diameter by spreading your fingers or squeezing them together.

2. Wrap the remainder of the roll, working around the ring to form a doughnut.

3. Place the dressing over the eye and the impaled object to hold the impaled object in place, and then secure it with gauze dressing. Be sure to cover both eyes.

Place the patient on a stretcher and transport promptly. Protect the eye from further injury with a metal shield. Cover the other eye to minimize movement on the injured side.

Cover each eye with a sterile, moist pad and an eye shield. Have the patient lie down during transport to the hospital. Protect the patient from further exposure to bright light.

Hold the patient's eyelid open. If only one eye is affected, take care to avoid contaminating the unaffected eye. Flush from the inner corner of the affected eye towards the outside corner. Irrigate the eye for 5 to 20 minutes. Apply a clean, dry dressing to cover the eye after irrigation. Transport the patient promptly to the hospital for further care.

1. Never exert pressure or manipulate the injured eye (globe) in any way.
2. If part of the eyeball is exposed , gently apply a mist sterile dressing to prevent drying.

3. Cover the injured eye with a protective metal eye shield, cup or sterile dressing. Apply soft dressings to both eyes, and provide prompt transport to the hospital.

First ensure that the scene is safe. Management depends on the severity of the injury. Do not attempt to remove a foreign body within the globe. Use a clean cup or similar item to protect the area. If only one eye is injured, follow local protocol, which may include covering the other eye to eliminate sympathetic motion. Patients with a sudden loss or decrease of vision will need to be verbally instructed on what actions are taking place around them. If the patient has severe swelling or a hematoma to the eyelid, do not attempt to force the eyelid open to examine the ye.

For a nontrauma patient who is bleeding from the nose, place the patient in a sitting position, leaning forward, and pinch his or her nostrals together.

Place a soft, padded dressing between the ear and the scalp. If the ear is avulsed, wrap it in a moist, sterile dressing and place it in a plastic bag. Keep the avulsed tissue cool and transport to the hospital with the patient. Leave any foreign object within the ear for the physician to remove. Note any clear fluid coming from the ear.

Remove and save loose teeth or bone fragments from the mouth and transport them with you. Remove any loose dentures or dental bridges to protect against airway obstruction. Maintain an open airway.

Apply direct pressure to stop the bleeding. Keep the airway open. Perform suctioning if needed. Handle the tooth by its crown and not by the root. Transport the patient. Bring along the tooth, placing it in either cold milk or sterile saline. Notify the receiving facility about the avulsed tooth.

If bleeding is uncontrollable and compromising the patient's airway, consider removing the impaled object if possible. Provide direct pressure on the inside and outside of the cheek. Bandaging should not occlude the mouth or make it difficult for the patient to breath.

1. Apply direct pressure to the bleeding site using a gloved finger tip if necessary to control the bleeding.
2. Apply a sterile occlusive dressing to ensure that air does not enter a vein or artery.
3. Use roller gauze to secure a dressing in place.
4. Wrap the bandage around and under the patient's shoulder.

Ensure scene safety and safe access to the patient. Standard precautions should include a minimum of gloves and eye protection if there is vomiting. Consider the possibility that facial injuries can cause bleeding into the oropharynx, producing coughing; therefore, consider the use of face shields. Consider donning a gown and shoe covers if other bodily fluids are involved. Determine the number of patients. Assess the need for additional resources

Determine the MOI. Interview the patient, family, and/or bystanders to determine the exact nature of the traumatic forces applied. Maintain a high index of suspicion for associated spinal injuries, especially with rapid acceleration-deceleration MOIs.

Inquire about the chief complain and observe the patient's overall body position. Observe the work of breathing and circulation. Determine the level of consciousness using the AVPU scale. Identify immediate threats to life. Determine the priority of care based on the MOI. If the patient has a poor general impression, call for ALS assistance. A rapid scan will help you identify and manage life threats. Maintain a high index of suspicion for airway or respiratory compromise.

Ensure the airway is open, clear, and self maintained. Evaluate the patient's ventilatory status for rate and depth of breathing, respiratory effort and tidal volume. Administer high-flow oxygen at 15 L/min, providing ventilatory support as needed. Hypoxia may cause changes in the patient's mental state. If vomiting or bleeding into the oropharynx is a possibility, tilt the backboard to the side after spinal immobilization has been performed and have suction ready

Observe skin color, temperature, and condition; look for life-threatening bleeding and treat accordingly. Evaluate distal pulse rate, quality (strength), and rhythm. Observe for significant oropharyngeal bleeding.

If the patient has an airway or breathing problem, signs and symptoms of bleeding, or other life threats, manage them immediately and consider rapid transport, performing the secondary assessment en route to the hospital. Consider rapid transport to an appropriate trauma center.

Conscious Patient (Scene Size-up, Primary Assessment, History Taking, Secondary Assessment, Reassessment)

Unconscious Patient (Primary Assessment, Full Body Scan, Vital Signs and Past Medical History from a family member or bystander).

Investigate the chief complaint. Monitor the patient for changes in mental status. Ask SAMPLE questions. SAMPLE can also be obtained from the family, bystanders and medical alert tags.

Perform a systematic full-body examination or a focused examination on the face and/or neck. Rule out any potential life threats. Advise the patient prior to performing any examination. Do not delay transport to perform the physical examination at the scene. Look for DCAP-BTLS (Deformity, Contusions, Abrasions, Punctures/Penetrations, Burns, Tenderness, Laceration, Selling) and asymmetry in the face and neck. Pay close attention to injuries that could potentially obstruct the airway or occlude blood flow to the brain.

Obtain baseline vital signs as soon as practical. Vital signs should include blood pressure by auscultation, pulse rate and quality, and skin assessment for perfusion. Note the patient's level of consciousness. Use pulse oximetry, if available, to assess the patient's perfusion status.

Reassess the primary assessment, vital signs, chief complaint, and any interventions already performed. Assist breathing as required, administering high-flow oxygen.

Trauma to the face and skull that results in the posterior wall of the nasal cavity becoming unstable.

Apply direct manual pressure with a dry dressing. Use roller gauze around the circumference of the head to hold the dressing in place. Make sure you do not apply excessive pressure if there is a possibility of an underlying skull fracture.

1. Apply direct pressure to the bleeding site using a gloved fingertip if necessary to control the bleeding.

2. Apply a sterile occlusive dressing to ensure that air does not enter a vein or artery.

3. Secure the dressing in place with roller gauze, adding more dressings if needed.

4. Wrap the gauze around and under the patient's shoulder. To avoid possible airway problems do not wrap the gauze around the neck.

Start on the outer aspect of the eye and work your way in toward the pupil.

Examine the eye for any obvious foreign matter.

Observe for discoloration of the eye.

Evaluate the clarity of the patient's vision.

Assess for redness of or bleeding into the iris.

Look for symmetry between the two eyes.

Assess the pupils for equal size and reaction to light.

Determine if unequal puipls are caused by physiologic or pathologic issues.

Determine if the patient is able to follow your finger with their eyes.

Assess visual acuity by having the read normal print.

Question about blurry vision or sensitivity to light.

1. Never exert pressure on or manipulate the injured eye (globe) in any way.

2. If part of the eyeball is exposed, gently apply a moist, sterile dressing to prevent drying.

3. Cover the injured eye with a protective metal eye shield, cup or sterile dressing. Apply soft dressings to both eyes, and provide prompt transport to the hospital

1. One pupil is larger than the other
2. The eyes not moving together or pointing in different directions.
3. Failure of the eyes to follow the movement of your finger as instructed.
4. Bleeding under the conjunctiva, which obscures the sclera of the eye.
5. Protrusion or bulging of one eye